January 22, 2008
Under 40 Mammogram Notes
This is an adult topic, but it’s not necessarily “adult.” The things talked about here are scientific in nature, not erotic.
So, I was researching this evening something that stuck in my head (a friend brought this up recently due to something she experienced) regarding Mammography. Basically, it’s an x-ray of breast tissue. Unfortunately, for shorter women, and women who aren’t well endowed, it often is difficult to get a Mammogram performed properly. To make matters worse, there is a slight increase in risk due to the gamma-radiation of the Mammogram for women under the age of 40. To top this all off, it turns out that women under the age of 40 often have regular breast density differences just due to their more active hormones, etc. There are apparently missed cancers in differing breast-mass Mammograms, as well as false-positives for differing breast-density which is often completely normal for women under 40. Very interesting.
A 1998 article on the subject  suggests that due to these factors, Mammography is not useful for younger women, and suggests that directed ultrasound examination be used to determine the type of mass and whether it is clinically suspect. The reason for the directed ultrasound is quite simple… if they go running around doing a complete ultrasound examination, they will likely find many more masses which are not suspect due to the differing breast density in younger women. Then, if the mass is clinically suspect, fine-needle aspiration which has an excellent rate of determining benign or malignant masses can be used. Then, decisions about what to do with both can be discussed. Benign of course you can simple do a follow-up clinical examination to determine if the mass has grown or not, and any other subsequent ultrasound or FNA can be done at that time.
Basically, Mammography has changed very little since the 1970s, and over a billion dollars spent in trying to update it to make it a better screening method has failed to improve it’s effectiveness.  Couple this with very low cancer rates in women below 40, the increase in risk due to radiation, and the density differences which cause false-positives, Mammography appears to be somewhat unimportant and unuseful for women under 40. One of the reasons I suspect it is a preferred test, is quite simply due to its cost. Cost appears to be $50-150.00, quite an easy bill to foot. The problem quite simply is that if it misses smaller masses and has false-positives on varying tissue density, it doesn’t appear that useful.
The reason this came up was quite simply because I was confused at the call for a mammogram in a friend who is well under 40 (actually under 35)… that lead me to dig a bit more, and I realized that the clinical suggestions are such that there is not much that indicates mammography in women that young. [Not just the screening procedures.] So, I feel quite likely this is another case of a doc (here a practitioner not an MD) just following rote the marching orders, failing to realize that age was an important factor here, and with a simple test, why not? Well, why not is quite simple- poor efficacy (false positives and false negatives) and an (albeit small) increase in gamma-radiation exposure. No reason to do so, why do it? Besides, that very same day (within a half-hour) she’s scheduled for an ultra-sound examination (I wonder if it’s a comprehensive US, or if it’s just directed- better be directed, or else I’ll think someone is not doing their job very well over there…). The ultrasound does a much better job at imaging masses in women this age, and will likely just confirm an earlier diagnosis of fibroadenoma for similar masses in the same patient.
I get quite tired of docs who can’t stay current with these things… I experienced this with another friend who had been mis-diagnosed with a very crazy disease. Reading and talking with the experts in the field revealed that quite likely the docs were being way over cautious, and that there was very little to indicate the extreme (and somewhat rare) disease classification was warranted.
In this litigation crazy world, however, I can understand overly cautious docs. Likely they’re doing everything they can for the first friend, simply because litigation of missed cancers in younger women is much much higher than in older women. So, again, litigation rules the marching orders for docs, not the actual science behind the medicine. The hippocratic oath suggests to me that even a slight gamma-radiation exposure when not warranted may be simply removed to prevent any slight possibility of complication in the future. Of course, if she was litigation crazy, she could simply suggest that any future breast cancer was likely caused by the non-indicated use of a mammogram while she was younger than 40. [How's that for a scare, hospital lawyers?]
Update: The first friend had her examinations today. She asked the practitioners again about the mammogram, but they gave her line something like: “We need the mammogram to help support the ultrasound.” So, she says to them: “Well, ok, I think I understand, but I’m going to wait on the mammogram right now because I’m uncomfortable with the test at this time.” She keeps her ultrasound appointment, is in and out for the test. (I had time to read maybe 2 long paragraphs and make notes for that chapter.) The ultrasound tech confirmed everything I said here, as well as suggested that for my friend, it would be a bad idea due to her breast size. The ultrasound went perfectly, did a fantastic job of imaging the mass, and it was found to be a simple fluid filled cyst. Had she gone ahead with her mammogram, she likely would have gotten a bazillion hits on different masses, and then the rush to find out which mass may be cancerous would begin. When, due to the extremely high false-positive rate (90%) for mammography, coupled with the under 40 cancer rate (less than 4%) every mass would likely be benign. I suggest an alternative method… create a grid of dots on the breasts, and do FNA’s all over the breast tissue. At least the efficacy would be significantly higher than in a Mammogram. [Of course I don't actually suggest this- but it would be more effective than mammography in young women. Likely you'd be doing FNA's all day long with all the masses that would show up in mammography.] Finally a simple disclaimer- I’m not an expert, I’ve just read some articles on this. So, don’t take all the above as rote. Find the actual journal articles, read them, and make up your own opinions. [It's surprising how easy it is to do.]
- M. Morrow, S. Wong, and L. Venta. The evaluation of breast masses in women younger than forty years of age. Surgery, 124(4):634–641, 1998. (via Science Direct)